Citation Nr: 0000917 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 97-20 295 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an increased (compensable) disability evaluation for service-connected bilateral hearing loss. 2. Entitlement to an increased (compensable) disability evaluation for service-connected right knee disability. 3. Entitlement to an increased evaluation for left knee disability, currently evaluated as 10 percent disabling. 4. Entitlement to an increased evaluation for right shoulder disability, currently evaluated as 10 percent disabling. 5. Entitlement to an increased (compensable) evaluation for service-connected disorder of the respiratory system. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T.J. Kniffen, Associate Counsel INTRODUCTION The veteran had active service from December 1975 to June 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal of a January 1997 rating decision from the Denver, Colorado Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection and assigned a disability rating of 10 percent for degenerative joint disease of the right shoulder and both knees and assigned noncompensable evaluations for bilateral hearing loss and a disorder of the respiratory system. By rating decision dated in November 1998, the RO assigned separate 10 percent evaluations for degenerative joint disease of the left knee and right shoulder, and assigned a noncompensable rating for degenerative joint disease of the right knee. The RO issued a supplemental statement of the case to the veteran on the same date that addressed the RO's revised rating of the veteran's right knee disability. Therefore, due process considerations have been satisfied. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. § 20.302 (c) (1999). The January 1997 rating decision also granted service connection for tinnitus and assigned an evaluation of 10 percent disabling. However, the veteran did not express disagreement with this determination. Therefore, this issue is not before the Board since the RO's determination regarding it is final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 20.200, 20.201,20.202, 20.302(a) (1999). FINDINGS OF FACT 1. The most recent audiologic evidence demonstrates that the veteran has an average pure tone threshold of 35 decibels in the right ear, with speech recognition ability of 100 percent, and an average pure tone threshold of 55 decibels in the left ear, with speech recognition ability of 96 percent. 2. The totality of competent and probative evidence of record demonstrates the veteran has no more than Level I hearing loss of the right ear and Level I hearing loss of the left ear. 3. The veteran's right knee disability is currently manifested by full range of motion with no evidence of chondromalacia of the patella. 4. The veteran's left knee disability is manifested by mild osteoarthritis with evidence of pain and tenderness with motion. 5. The veteran's left shoulder disability is currently manifested by full range of motion with no discomfort. 6. The veteran's respiratory disability is currently manifested by subjective complaints of coughing without expectoration, loss of weight or incapacitating episodes of infection. Pulmonary function testing conducted in August 1997 revealed FEV-1 to be 97 percent of predicted value. FEV-1/FVC was 85 percent. CONCLUSIONS OF LAW 1. The criteria for a compensable schedular evaluation for bilateral hearing loss are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.85, Diagnostic Code 6100. (1999). 2. The criteria for a compensable evaluation for service- connected right knee disability are not met. 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. §§ 4.71, 4.71a, Diagnostic Codes 5010, 5257, 5260, 5261 (1999). 3. The criteria for an increased evaluation for left knee disability, has not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5260, 5261 (1999). 4. The criteria for an increased evaluation for service- connected right shoulder disability are not met. 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. §§ 4.71, 4.71a, Diagnostic Codes 5010, 5202, 5203(1999). 5. The criteria for a compensable evaluation for service- connected respiratory disability are not met. 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. § 4.97, Diagnostic Codes 6600, 6601 (1996); 38 C.F.R. § 4.97, Diagnostic Codes 6600, 6601 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters Initially, the Board concludes that the veteran's claim of entitlement to an increased evaluations for bilateral hearing disorder, right and left knee disability, right shoulder disability and respiratory disorder are well grounded within the meaning of the statutes and judicial construction. See 38 U.S.C.A. § 5107(a) (West 1991). When a veteran is awarded service connection for a disability and appeals the RO's rating determination, the claim continues to be well grounded as long as the claim remains open and the rating schedule provides for a higher rating. See Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). Upon the submission of a well-grounded claim, the VA has a duty to assist the veteran in developing the facts pertinent to his claim. 38 U.S.C.A. § 5107. In the instant case, there is ample medical and other evidence of record, the veteran has been provided a recent VA examination, the RO made extensive efforts to obtain the veteran's complete service medical records and there is no indication that there are additional available records that have not been obtained and which would be pertinent to the present claim. Thus, no further development is required in order to comply with VA's duty to assist as mandated by 38 U.S.C.A. § 5107(a). Laws and regulations applicable to all issues on appeal Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2 (1999), which require the evaluation of the complete medical history of the veteran's condition. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson v. West, 12 Vet. App.119 (1999), however, the United States Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. Since this is an appeal of an initial rating assignment, the Board is not limited to consideration of the current diagnosis of the veteran's disabilities. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1999). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to an increased (compensable) disability evaluation for service-connected hearing loss Relevant law and regulations Under current VA regulations, the severity of hearing loss is determined by comparison of audiometric test results with specific criteria set forth at 38 C.F.R. § 4.85, Part 4, Diagnostic Code 6100. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000 and 4,000 Hertz (cycles per second). The Schedule allows for such audiometric test results to be translated into a numeric designation ranging from Level I, for essentially normal acuity, to Level XI, for profound deafness, in order to evaluate the degree of disability from bilateral service- connected defective hearing. The evaluations derived from the schedule are intended to make proper allowance for improvement by hearing aids. 38 C.F.R. § 4.86 (1999). Factual background In August 1995 the veteran presented for a medical evaluation board physical examination. He was diagnosed with bilateral high frequency sensory neural hearing loss. In August 1996 the veteran presented for a VA physical examination that included audiologic tests. On the authorized audiologic evaluation , pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 20 20 35 50 LEFT 20 35 50 80 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 100 percent in the left ear. In August 1997 the veteran presented for a VA audiologic examination. On the authorized audiologic evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 25 25 35 55 LEFT 30 40 60 90 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 96 percent in the left ear. It was indicated that the veteran had a mild hearing loss in the right ear and a moderate loss in the left ear. Analysis The assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendemann v. Principi, 3 Vet. App. 345 (1992). The most recent VA audiologic evaluation available (August 1997) reveals an average pure tone threshold of 35 decibels in the right ear, and a speech discrimination ability of 100 percent in the right ear. The audiologic evaluation also reveals an average pure tone threshold of 55 decibels in the left ear, and a speech discrimination ability of 96 percent in the left ear. Applying these values to the 1987 rating schedule, which was in effect when the veteran filed his claim, and new 1999 rating schedule (See discussion below) results in a numeric designation of Level I hearing in the right ear and Level I in the left ear. Under DC 6100, a noncompensable evaluation is assigned where hearing is at Level I bilaterally, which 38 C.F.R. § 4.87 (1998) and 38 C.F.R. § 4.85 (1999), Table VII provides. The Board also notes that effective June 10, 1999, regulations applicable to compensable service connected hearing loss were revised. 64 Fed. Reg. 25206 (May 11, 1999). The Court has held that where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran will apply. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). A comparison of the 1987 and 1999 VA regulations pertaining to evaluation of hearing loss with the August 1996 and 1997 audiometric examinations is necessary in view of Karnas. Application of the average pure tone thresholds and speech recognition scores from the August 1996 audio examination, to the 1987 and new, current regulation, (Table VII, 38 C.F.R. § 4.87 and; 38 C.F.R. § 4.85 ), results in a bilateral non- compensable evaluation. The Board notes the same result in connection with the August 1997 audio examination. Therefore, the Board concludes that the change in regulations has no impact upon the outcome of the veteran's claim for compensable service-connected hearing loss. See Edenfield v. Brown, 8 Vet. App. 384 (1995). The Board also concludes that consideration of all medical examinations since the veteran filed his claim results in the same conclusion, that a compensable disability rating for his service-connected hearing loss is not warranted at any time. See Fenderson. Therefore, the clinical evidence of record does not support the veteran's claim. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a compensable evaluation for bilateral hearing loss. The benefit sought on appeal is denied. In Bernard v. Brown, 4 Vet. App. 384 (1993), the Court of Veterans Appeals held that before the Board addresses in a decision a question that has not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument, an opportunity to submit such evidence or argument, an opportunity to address the question at a hearing, and whether the claimant has been prejudiced by being denied those opportunities. In this case, the RO did not consider the new diagnostic regulations relating to rating of service- connected hearing loss that became effective June 10, 1999. The Board notes, as previously stated, that application of the new regulations would not result in an increased evaluation for service-connected bilateral hearing loss for the veteran. Therefore, the veteran has not been prejudiced and has been accorded sufficient due process considerations. 2. Entitlement to an increased (compensable) evaluation for service-connected right knee disability. Applicable laws and regulations Diagnostic Code 5260 provides for limitation of the flexion of the leg. Where flexion is limited to 60 degrees, a 0 percent rating is provided; when flexion is limited to 45 degrees, 10 percent is assigned; when flexion is limited to 30 degrees, 20 percent is assigned; and when flexion is limited to 15 degrees, 30 percent is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (1999). Limitation of extension of the leg is rated 50 percent at 45 degrees, 40 percent at 30 degrees, 30 percent at 20 degrees, 20 percent at 15 degrees, 10 percent at 10 degrees, and noncompensable at 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1999). See also 38 C.F.R. § 4.71, Plate II (1999) which reflects that normal flexion and extension of a knee is from 0 to 140 degrees. Under Diagnostic Code 5257, the schedular criteria call for a 10 percent disability rating for slight impairment of a knee. A 20 percent disability rating is warranted for moderate impairment, and a 30 percent disability rating is assigned for severe impairment. 38 C.F.R. § 4.31, Diagnostic Code 5257 (1999). The words "slight", "moderate" and "severe" are not defined in the VA Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (1999). It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. § 4.2 (1999). Under Diagnostic Code 5010, traumatic arthritis, when substantiated by x-ray findings, will be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis when established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation will be established where x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbation; a 10 percent evaluation shall be established for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) of Diagnostic Code 5003 states that the 20 and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court held that evaluations for distinct disabilities resulting from the same injury could be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. The VA Office of General Counsel provided guidance concerning increased rating claims for knee disorders. See VAOPGCPREC 23-97. The General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that any: . . . separate rating must be based upon additional disability. When a knee disorder is already rated under [Diagnostic Code] 5257, the veteran must also have limitation of motion under [Diagnostic Code] 5260 or [Code] 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero- percent rating under either of those codes, there is no additional disability for which a rating may be assigned. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (1999) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (1999). See 38 C.F.R. § 4.71a, Diagnostic Code 5003, DeLuca v. Brown, 8 Vet. App. 202 (1995). Factual Background Service medical records reflect the veteran complained in February 1990 of bilateral knee pain. He reported a grinding sensation and pain while walking. The examiner's objective findings included grinding with no effusion and full range of motion. X-rays were taken of the veteran's right and left knees in October 1990. It was concluded that they showed the beginning of patella osteophyte formations, but no other abnormalities were noted. The veteran complained of two year history of bilateral knee pain in February 1992. He stated that prolonged usage causes pain which was noted by the examiner upon palpation. A grating noise was also noted by the examiner as was full range of motion. No swelling was noted by the examiner who diagnosed the veteran with bilateral patellar fermal malalignment. The veteran presented for x-rays of his right and left knees in February 1992. The findings included mild joint space narrowing medially on both knees and mild sclerosis of the tibial articulating surfaces. Minimal peaking of the tibial spines was noted in the left knee. Lateral viewed demonstrated small spurs superiorly and inferiorly in the left patella and inferiorly on the right patella. The examiner diagnosed the veteran with mild degenerative changes in both knees and the patella, more prominent in the left. In December 1992 the veteran again reported left and right knee pain, right knee worse than left. No swelling was noted by the examiner who indicated a grinding sensation in the joints below the kneecap. The veteran was diagnosed with degenerative joint disease and patellar femoral malalignment in both knees. In January and March 1993 the veteran reported pain in both his right and left knees. Full range of motion was noted by the examiner who diagnosed the veteran with malalignment syndrome in both knees. In November 1993 the veteran was hospitalized for right knee arthroscopic lateral retinacula release surgery. His pre and postoperative diagnoses was right knee patellar malalignment. The veteran was examined in May 1994 as a follow up to the right and left knee surgical procedures. The examiner assessed the veteran's right knee as asymptomatic. Regarding the veteran's left knee, the examiner noted patellar pain in the left knee with no effusion and diagnosed the veteran with medial femoral condyle in the left knee and chondromalacia patellae in both knees. The veteran was examined in April 1995 as a follow up to the three knee related surgical procedures. The examiner noted full range of motion with no effusion in the veteran's left and right knees. The ligaments were stable. The veteran was diagnosed with chondromalacia patellar, worse in the right knee than the left knee. In August 1995 the veteran presented for a medical evaluation board physical examination. The veteran complained of bilateral knee pain and he was diagnosed with bilateral retropatellar chondromalacia. As part of the veteran's VA medical examination in August 1996, his right and left knees were examined. The veteran reported continued right and left knee discomfort especially when he exercised. Physical examination did not reveal heat, swelling or redness. Range of motion was 0 to 130 degrees, bilaterally. Lateral and medial ligaments were found to be intact. Anterior and posterior drawer tests were negative. His gait was normal. An accompanying x-ray of the veteran's right and left knees showed minimal degenerative changes, bilaterally. The overall diagnosis was bilateral retropatellar chondromalacia, right and left knees (grade IV). In June 1997 the veteran sought treatment from R.B., M.D. Examination of the veteran showed some tightness in the right knee, motion of the right patella also caused pain. No joint line tenderness or narrowing of the right knee joints was noted. Some lateral subluxation was noted. Dr. R.B. diagnosed the veteran with probable patellofemoral instability of the right knee. In July 1997 Dr. R.B. noted full range of motion in the veteran's right knee. The veteran presented for a VA examination in September 1997. He reported daily discomfort in his right knee that was aggravated by climbing stairs, entering and exiting his vehicle and standing for more than fifteen minutes. Examination of his right knee revealed range of motion to 140 degrees, negative anterior drawer, Lachman's and McMurray's. Examination also revealed stable medial and lateral collateral ligaments with no evidence of chondromalacia of the patella. The veteran was diagnosed with status post lateral release procedure for patellofemoral syndrome, with discomfort as described. As part of the September 1997 examination, x-rays were done of the veteran's right knee. Revealed was mild degenerative osteophytes of the tibial spines and femoral condyles and minimal lateral subluxation of the patella. The examiner's impression of the veteran's right knee and patellofemoral joints was mild osteoarthritis Analysis The Board has carefully reviewed the medical evidence, which has been reported in detail above. Specifically during the most recent VA examination, the examiner noted full range of motion in the veteran's right knee (140 degrees) and no evidence of chondromalacia of the patella. Examiners in 1992, 1993, 1995 and 1996 reported full range of motion in the veteran's right knee with an asymptomatic diagnosis in 1994. Therefore the criteria for a compensable rating under Diagnostic Codes 5260 and 5261 are not present. The Board also notes that even though the veteran reported pain in his right knee and was diagnosed in 1997 with mild osteoarthritis, at no time did physical examination show swelling or muscle spasm in the veteran's right knee. Further, x-rays did not show involvement of the required joints under Diagnostic Code 5010. As such, the criteria applicable to a compensable rating under Diagnostic Code 5010 are not present. Accordingly, a noncompensable disability rating is warranted. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). However, symptoms evidencing slight or moderate impairment of the veteran's right knee have not been reported by medical examiners who have conducted examinations of the veteran's right knee. See 38 C.F.R. § 4.71, 4.71a, Diagnostic Code 5257 (1999). The Board has also considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher disability evaluation. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). However, the September 1997 examination report reflects that the veteran was able to achieve full range of motion. Although the Board has taken into consideration the veteran's complaints of pain, there is no objective evidence of functional loss due to pain, weakened movement, fatigability or incoordination. In this respect, the Board places greater weight on the objective VA medical examination than on the veteran's statements. The Board therefore concludes that the additional factors to be considered under 38 C.F.R. §§ 4.40 and 4.45 are not present in this case. In summary, for the reasons and bases expressed above, the Board concludes that the preponderance of the evidence is against the veteran's claim of entitlement to an increased disability rating for his service-connected right knee disability. The benefit sought on appeal is accordingly denied. 3. Entitlement to an increased evaluation for left knee disability, currently evaluated as 10 percent disabling. Applicable laws and regulations The laws and regulations applicable to the veteran's service- connected right knee disability are applicable to the following Analysis. Factual background Reference is made to the Factual background regarding the veteran's right knee disability for a description of treatment of his left knee from 1990 to 1993. In April 1993 the veteran was hospitalized on account of bilateral knee pain, left knee worse than right. He was diagnosed with bilateral retropatellar pain syndrome, possibly secondary to tight lateral retinaculum, left knee chondromalacia. Left knee arthroscopic lateral release and retropatellar shave surgery, with debridement of retropatellar chondromalacia, was performed. As stated previously, the veteran was examined in May 1994 as a follow up to the right and left knee surgical procedures. Regarding the veteran's left knee, the examiner noted patellar pain in the left knee with no effusion and diagnosed the veteran with medial femoral condyle in the left knee and chondromalacia patellae in both knees. In September 1994 a magnetic resonance imaging test (MRI) was performed on the veteran's left knee. No evidence of chondromalacia was found. In November 1994 the veteran was again hospitalized on account of left knee chondromalacia. Arthroscopic debridement chondromalacia patella, left knee surgical procedure was performed. In December 1994 the veteran reported improvements in his left knee. The veteran was examined in April 1995 as a follow up to the three knee related surgical procedures. The examiner noted full range of motion with no effusion in the veteran's left knee. The veteran was diagnosed with chondromalacia patellar, worse in the left than right knee. Regarding the August 1996 VA examination and the veteran's left knee, reference is made to the Factual background section of this decision in connection with the right knee. In June 1997, Dr. R.B. reported the veteran's complaints of constant ache in the anterior compartment of the left knee, as well as the sensation that his kneecap will give and dislocate. He did not fell that the kneecap actually dislocated. The veteran stated that walking up stairs, squatting and kneeling aggravates his left knee. Examination of the veteran's left knee revealed pain with motion, minimal subpatellar crepitation and considerable subpatellar tenderness. Lateral retinaculum is limited, no joint line tenderness and the left knee was noted as stable. No narrowing of the joints of the left knee was noted. Substantial lateral subluxation and tilt of the left patella were noted with no sclerosis or significant osteophytic change. Dr. R.B. diagnosed the veteran with patellofemoral instability of the left knee with patellofemoral arthritis. During a July 1997 follow up examination the veteran indicated his left knee was still painful Regarding the veteran's September 1997 VA examination, in addition to previously noted complaints for both the right and left knees, the veteran reported that his left knee became swollen once every two weeks and he sensed slipping in the left patella, but denied any locking in the left knee. The veteran stated his left knee was much more painful than his right knee because of discomfort from the grinding sensation. The veteran reported twice per week flare ups in his left knee. The accompanying left knee x-ray indicated mild degenerative osteophytes of the femoral condyles, small osteophyte in the inferior patella and possible lateral subluxation of the patella. The examiner's impression of the x-ray of the left knee was mild degenerative osteoarthritis and patellofemoral joints. Physical examination of the left knee resulted in the same findings as for the right knee except crepitance and discomfort with testing for patellofemoral syndrome were noted. As with the right knee, examination of the veteran's left knee in September 1997 revealed range of motion to 140 degrees, negative anterior drawer, Lachman's and McMurray's. The examiner concluded the examination of the veteran's left knee by evaluating fatigability, instability and incoordination. The veteran performed ten squatting motions. After doing so, the veteran reported an increase in subpatellar pain. No range of motion limitations or evidence of fatigability, instability or incoordination was noted. Regarding his left knee the veteran was diagnosed with status post lateral release procedure, debridement with residuals and sequelae of patellofemoral syndrome and degenerative changes. Analysis As with the veteran's right knee, the Board has carefully reviewed the medical evidence, which has been reported in detail above. The Board notes the September 1997 VA examination, where the examiner noted full range of motion in the veteran's left knee (140 degrees) Therefore, the criteria for a compensable rating under Diagnostic Codes 5260 and 5261 are not present. The Board does note, however, that Dr. R.B reported in 1997 that examination of the veteran's left knee revealed pain in motion, minimal subpatellar crepitation and considerable tenderness. Different from VA examination of the veteran's right knee in 1997, the VA examiner reported findings of crepitance and discomfort when examining the veteran's left knee, justifying a 10 percent disability rating under Diagnostic Code 5010. As stated previously, the assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). However, symptoms evidencing slight or moderate impairment of the veteran's right knee have not been documented by medical examiners who have conducted examinations of the veteran's left knee. See 38 C.F.R. § 4.71, 4.71a, Diagnostic Code 5257 (1999). The Board has also considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher disability evaluation. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). However, the September 1997 examination report reflects that the veteran was able to achieve full range of motion. Further, the VA examiner conducted testing designed to reveal any fatigability, instability or incoordination in the veteran's left knee and made no findings of any such range of motion limitations. Although the Board has taken into consideration the veteran's complaints of pain, there is no objective evidence of functional loss due to pain, weakened movement, fatigability or incoordination. In this respect, the Board places greater weight on the objective VA medical examination than on the veteran's statements. The Board therefore concludes that the additional factors to be considered under 38 C.F.R. §§ 4.40 and 4.45 are not present in this case. In summary, for the reasons and bases expressed above, the Board concludes that the preponderance of the evidence is against the veteran's claim of entitlement to an increased disability rating for his service-connected left knee disability. The benefit sought on appeal is accordingly denied. 4. Entitlement to an increased evaluation for right shoulder disability, currently evaluated as 10 percent disabling. Applicable law and regulations Diagnostic Code 5202 pertains to other impairment of the humerus. A 20 percent evaluation (the lowest available rating under Diagnostic Code 5202) is warranted for malunion of the humerus of the major or minor upper extremity with moderate deformity. A 20 percent evaluation is also warranted where there are infrequent episodes of dislocation of the scapulohumeral joint of the major or minor upper extremity with guarding of movement only at the shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5202 (1999). Diagnostic Code 5203 pertains to impairment of the clavicle and scapula. A 20 percent rating is warranted where there is dislocation of the clavicle or scapula, or nonunion of the clavicle or scapula with loose movement. These ratings apply to either the major or minor upper extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (1999). Under Diagnostic Code 5010, traumatic arthritis, when substantiated by x-ray findings, will be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis when established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion of the arm is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, which provides for a 20 percent rating (the lowest available rating) where motion of the major or minor arm is limited to the shoulder level. A 30 percent rating is warranted where motion of the major arm is limited midway between the side and shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (1999). Normal range of motion for the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation will be established where x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbation; a 10 percent evaluation shall be established for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) of Diagnostic Code 5003 states that the 20 and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court held that evaluations for distinct disabilities resulting from the same injury could be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (1999) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (1999). See 38 C.F.R. § 4.71a, Diagnostic Code 5003, DeLuca v. Brown, 8 Vet. App. 202 (1995). Factual background During the August 1995 medical evaluation board physical examination the veteran complained of right shoulder pain and weakness. This examination indicates the veteran suffered a right acromioclavicular (AC) joint separation in September 1984 and a Mumford procedure was performed in September 1995. X-rays indicated degenerative changes at the outer end of the right clavicle. He was diagnosed with degenerative joint disease of the right acromioclavicular joint. During the August 1996 VA examination, it was noted that the veteran is right-handed. The veteran reported continued intermittent pain in his right shoulder from time to time with no heat, swelling or redness. Examination of the right shoulder did not disclose heat, swelling or redness. A well- healed surgical scar was noted over the AC joint on the right side. Range of motion of the right shoulder disclosed anterior flexion from 0 to 180 degrees, abduction from 0 to 180 degrees and internal and external rotation from 0 to 90 degrees. Discomfort was noted when extreme internal rotation was completed. Extension was 0 to 45 degrees. The veteran successfully displayed full range of motion using a five- pound weight. X-rays that accompanied the August 1996 examination revealed increased distance between the acromion and clavicle measuring approximately three centimeters. Noted was irregularity with osteophyte formation of the distal clavicle, the glenohumeral joint was normal. The diagnosis was degenerative joint disease with a history of right AC joint, status post Mumford procedure with functional status as described. In June 1997, Dr. R.B. noted his examination of the veteran's right shoulder revealed mild tenderness over the resected AC joint. There was no upriding of the clavicle with downward pull on the arm and the veteran's right shoulder was otherwise unremarkable. Dr. R.B. diagnosed the veteran with status post resection of outer clavicle for AC separation with reconstruction of ligaments. During the September 1997 VA examination the veteran reported aches in his right shoulder after laying upon it for extended periods of time or lifting more than thirty pounds. A postal employee, the veteran stated that mail sacks weigh approximately forty pounds. Physical examination revealed right shoulder full range of motion. Abduction and flexion were 0 to 180 degrees and internal and external rotation from 0 to 90 degrees. No evidence of atrophy was noted. Concerning possible fatigability, weakness or incoordination, the veteran was asked to perform five abductions with his right shoulder carrying 2.5 pounds, which he performed without difficulty. He also performed without difficulty, five abductions of his right shoulder with five pounds. The veteran's right shoulder was then again tested for range of motion. He evidenced abduction from 0 to 175 degrees with minimal decrease in range of motion. No evidence of fatigability, weakness or incoordination was noted. The right shoulder x-ray that accompanied the September 1997 VA examination revealed widening of the AC joint with irregular distal clavicle. The general diagnosis of the veteran's right shoulder was status post surgical repair of AC separation with residuals of discomfort, loss of activities and post surgical changes. Analysis The veteran's right shoulder disability is currently assigned a 10 percent disability rating under Diagnostic Code 5010 and 5003 as arthritis. A 20 percent rating is assignable for dislocation of the clavicle or scapula of the major or minor extremity. A 20 percent rating may also be assigned for nonunion of the clavicle or scapula with loose movement. Without loose movement, a 10 percent rating is assignable. A 10 percent rating may also be assigned for malunion of the clavicle or scapula. Diagnostic Code 5203. A 30 percent evaluation may be assigned for limitation of motion of the arm of the major extremity midway between the side and shoulder level or at the shoulder level. When the limitation of motion is to the shoulder level, a 20 percent evaluation is assignable. Diagnostic Code 5201. In this case, there is no evidence of malunion of the shoulder. Specifically during the most recent VA examination, no deformity of the shoulder was noted and there is no other evidence of record which indicates that malunion of the shoulder exists. Similarly, other criteria applicable to higher ratings under Diagnostic Code 5203, such as dislocation or nonunion of the shoulder joint, are not present. Accordingly, a higher disability rating under Diagnostic Code 5203 is not warranted. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). However, such symptoms as ankylosis of the shoulder (Diagnostic Code 5200), limitation of motion of the upper extremity (Diagnostic Code 5201) and impairment of the humerus (Diagnostic Code 5202) are lacking in this case. The Board has also considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 warrant the grant of a higher disability evaluation. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The Board notes that the August 1996 VA examination demonstrated that the veteran experienced some discomfort at the extreme of internal rotation. There was no clinical evidence, however, of fatigability, functional loss due to pain or weakened movement. Moreover, the September 1997 examination report reflects that the veteran was able to achieve full abduction and forward elevation. The examiner specifically noted that there was no decrease in range of motion upon repetitive motions. Although the Board has taken into consideration the veteran's complaints of pain, there is no objective evidence of functional loss due to pain, weakened movement, fatigability or incoordination. In this respect, the Board places greater weight on the objective VA examination than on the veteran's statements. The Board therefore concludes that the additional factors to be considered under 38 C.F.R. §§ 4.40 and 4.45 are not present in this case. In summary, for the reasons and bases expressed above, the Board concludes that the preponderance of the evidence is against the veteran's claim of entitlement to an increased disability rating for his service-connected right shoulder disability. The benefit sought on appeal is accordingly denied. 5. Entitlement to an increased (compensable) evaluation for service-connected respiratory disease Applicable law and regulations Since the veteran filed his claim for an increased rating for disability of the respiratory system, the regulations pertaining to evaluation of the respiratory system were amended, effective October 7, 1996. As previously stated, where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant will apply. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). In light of the fact that the veteran filed his claim before November 7, 1996, the Board will evaluate his respiratory disability in light of both the new and old rating criteria. The May 1997 statement of the case reflects that both sets of rating criteria were applied to the veteran's claim. Accordingly, the veteran will not be prejudiced if the Board proceeds with appellate consideration of the claim presented. See Bernard v. Brown, 4 Vet. App. 384 (1993). Diagnostic Code 6601 Bronchiectasis is ordinarily rated under 38 C.F.R. § 4.97, Diagnostic Code 6601. Under the previous rating criteria, a 30 percent disability evaluation requires moderate bronchiectasis manifested by persistent paroxysmal coughing occurring at intervals throughout the day and by abundant purulent and fetid expectoration, but with slight, if any, emphysema or loss of weight. The next higher evaluation under Diagnostic Code 6601, 60 percent, requires severe bronchiectasis with considerable emphysema, impairment in general health manifested by loss of weight, anemia, or occasional pulmonary hemorrhages, and occasional exacerbations of a few days duration, with expected fever and other symptoms, and the disability is demonstrated by lipoidal injection and layer sputum test. A 100 percent rating is assigned when the disability is pronounced, with symptoms in aggravated form, marked emphysema, dyspnea at rest or on slight exertion, cyanosis, marked loss of weight or other evidence of severe impairment of general health. 38 C.F.R. § 4.97, Code 6601 (in effect prior to October 7, 1996). The Board observes that the words "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (1998). It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a) (West 1991); 38 C.F.R. §§ 4.2, 4.6 (1999). Under the amended criteria for bronchiectasis, a 30 percent disability rating is warranted for bronchiectasis when the disability is manifested by incapacitating episodes of infection of two to four weeks total duration per year, or daily productive cough with sputum that is at times purulent or blood-tinged and requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. An incapacitating episode is defined as one that requires bed rest and treatment by a physician. 61 Fed. Reg. 46,729. A 60 percent rating under the revised regulations is warranted if there are incapacitating episodes of infection of four to six weeks total duration per year, or near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. A 100 percent rating is warranted when there are incapacitating episodes of infection of at least six weeks total duration per year. For rating purposes, an incapacitating episode is one that requires bedrest and treatment by a physician. 38 C.F.R. § 4.97, Code 6601 (1999). Diagnostic Code 6600 The amended version of Diagnostic Code 6601 further provides that bronchiectasis can also be rated according to pulmonary impairment as for chronic bronchitis, 38 C.F.R. § 4.97, Diagnostic Code 6600. Pursuant to that Diagnostic Code, a 30 percent evaluation is warranted for a FEV-1 of 56 to 70 percent of predicted value, or FEV-1/FVC of 56 to 70 percent, or a Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 56 to 65 percent of predicted value. A 60 percent rating will be assigned where a FEV-1 is 40 to 55 percent of predicted, or FEV-1/FVC is 40 to 55 percent of predicted, or DLCO (SB) is 40 to 55 percent of predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). 38 C.F.R. § 4.97, Diagnostic Code 6600. Factual background In March 1990 the veteran reported a history of asthma. The finding of the examiner was bronchitis. In November 1990 the veteran reported symptoms of a head cold. The examiner diagnosed him with possible bronchitis. The veteran complained of congestion, sore throat and cough in October 1993. The diagnosis was possible bronchitis. In July 1994 the veteran presented with complaints of an abnormal temperature and cough. The examiner ruled out bronchitis as a diagnosis. However, in August 1994 the veteran reported the same complaints and wheezing. The veteran was diagnosed with right middle and lower lobe pneumonia. In July 1995 the veteran presented for x-rays of his chest. The examiner interpreted the x-rays as showing enlarged left hilar shadow raising suspicion of adenopathy, irregular outline of the outer end of the right clavicle compatible with degenerative changes that could be secondary to prior trauma. The August 1995 physical examination included discussion of the veteran's history of hilar adenopathy. The examiner made reference to the July 1995 chest x-ray that showed hilar adenopathy and a computed axial tomography (CT) examination of the veteran's chest that showed small lymph nodes in the pericranial, subcranial and left hilar areas. No pulmonary infiltrates were noted. The diagnosis was hilar adenopathy with unknown etiology and mild restrictive pulmonary function abnormality, possibly a reaction to a fungal infection. During a September 1995 examination the veteran was again diagnosed with hilar and mediastinal nodes, most likely sarcoidosis. A pathology report reflects that biopsies of the veteran's lung, left upper lobe, demonstrated bronchial wall with no significant pathologic changes. In October 1995 the veteran was hospitalized and underwent cervical mediastinal exploration (CME). This surgical procedure, according to the examiner, eliminated sarcoidoses as a diagnosis. The veteran was examined in November 1995 and March 1996. Clinical notes reflect the etiology for the veteran's mediastinal adenopathy remained undefined. VA emergency treatment notes indicate the veteran sought treatment for chest pains, fever and cough in August 1996. He was diagnosed with bronchitis. The August 1996 VA examination indicated the veteran did not show shortness of breath, chronic cough hemoptysis, fever, chills or weight loss when he was first diagnosed with hilar adenopathy in 1995. A bronchoscopy and gallium scan were normal. Observation of the veteran since the original diagnosis revealed no changes. Examination of the veteran's chest revealed normal breath tones and no wheezes, crackles or ronchi. Percussion note was normal. The accompanying chest x-ray revealed radiopaque densities overlaying the sternoclavicular junction, clear lungs with no evidence of infiltrates, nodules or effusions. The left hilum was demonstrated as prominent. The examiner's impression was subtle prominence of the left hilum, questionable adenopathy. Pulmonary function studies reflected a FVC reading of 99 percent, pre-treatment, FEV-1 reading of 104 percent pre- treatment and FEV-1/FVC reading of 86 percent. The examiner noted a very minimal restrictive disorder, no shortness of breath, dyspnea on exertion, chronic cough or excessive sputum production. The veteran was diagnosed with hilar adenopathy (pulmonary) of unknown etiology, asymptomatic. A pulmonary function study by a service department facility in August 1997 revealed FVC of 97 percent, FEV-1 of 77 percent and pev-1/FVC of 80 percent. During the September 1997 VA medical examination the veteran denied a history of tuberculosis. He stated he probably experienced bronchitis twice annually requiring medical attention. The veteran also denied a history of asthma, but stated he coughs every day. Upon examination the veteran's chest was clear to auscultation and percussion with no evidence of rales, rhonchi or wheezing. The accompanying chest x-ray reveal normal heart and mediastinum, unremarkable right helum. The left helum, however showed markedly increased soft tissue, mildly increased from the 1996 examination. The radiologist's impression was increased soft tissue at the left hilum, differential included adenopathy, dilated pulmonary artery versus much less likely AV malformation. Pulmonary function studies reflected a FVC reading of 93 percent, FEV-1 reading of 97 percent and FEV-1/FVC reading of 85 percent. The veteran was diagnosed with hilar adenopathy, unknown etiology, normal spirometry with decrease in FVC and FEV comparative with restrictive lung disease. Analysis The Board notes that the veteran's reported medical history lack reports of persistent paroxysmal coughing, abundant purulent and fetid expectoration, slight emphysema or loss of weight (former Diagnostic Code 6601). Under the current Diagnostic Code 6601, the record does not reflect incapacitating episodes of infection of two to four weeks per year even though the veteran reported experiencing bronchitis symptoms sometimes twice annually. His medical record does not show daily productive cough with sputum at times purulent that requires prolonged antibiotic usage more than twice per year. Therefore, the criteria for a compensable evaluation under either the former or current Diagnostic Code 6601 are not met. Regarding Diagnostic Code 6600, a 30 percent evaluation is warranted for a FEV-1 of 56 to 70 percent of predicted value or FEV-1/FVC of 56 to 70 percent. Both the August 1996 and August 1997 pulmonary tests exceed these compensable thresholds. Further, in August 1997 the examiner evaluated the pulmonary test results as normal. In summary, for the reasons and bases expressed above, the Board concludes that the preponderance of the evidence is against the veteran's claim of entitlement to an increased disability rating for his service-connected respiratory disorder. The benefit sought on appeal is accordingly denied. ORDER Entitlement to an increased (compensable) disability evaluation for service-connected bilateral hearing loss, is denied. Entitlement to an increased (compensable) disability evaluation for service-connected right knee disability, is denied. Entitlement to an increased evaluation for left knee disability, currently evaluated as 10 percent disabling, is denied. Entitlement to an increased evaluation for right shoulder disability, currently evaluated as 10 percent disabling, is denied. Entitlement to an increased (compensable) evaluation for service-connected disorder of the respiratory system, is denied. James R. Siegel Acting Member, Board of Veterans' Appeals